Healthcare Provider Details

I. General information

NPI: 1013492040
Provider Name (Legal Business Name): JESSICA VANDEVELDE LCSW-A
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/25/2018
Last Update Date: 06/01/2023
Certification Date: 06/01/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15 DAWN RD # 2
PINEHURST NC
28374-9123
US

IV. Provider business mailing address

12281 WOODRUN DR
LAURINBURG NC
28352-2055
US

V. Phone/Fax

Practice location:
  • Phone: 910-585-6108
  • Fax:
Mailing address:
  • Phone: 586-419-2608
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041S0200X
TaxonomySchool Social Worker
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberP018926
License Number StateNC

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: